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Patient Satisfaction Survey

Dear Patient,

Would you take a few minutes of your time to help us?

There are only 8 questions listed below.  We also welcome any comments you might want to provide.

Our goal is to provide comfort, convenience, and satisfaction as well as the very best medical care to all our patients. We’d like to know how you feel about our medical services, our patient-handling systems, our physicians and staff members. Your comments will help us evaluate our operations to ensure we are truly responsive to your needs.

Thank you for your help.

 

 1.   Name of Physician:     

2.  Office Location:         

PLEASE RATE THE FOLLOWING:

( Excellent ) ( Very Good ) ( Good ) ( Fair ) ( Poor ) ( Not Applicable )

3.  Your Appointment:  

Based on:

  • Ease of making appointments by phone:  

  • Appointment available within a reasonable amount of time:

  • The efficiency of the check-in process:   

  • Waiting time in reception area:   

  • Waiting time in the exam room:  

  • Keeping you informed if your appointment time was delayed:      

  • The courtesy of the person who took your call:       

  • The friendliness and courtesy of the receptionist:  

  • The technical skills of our nurses/medical assistants/technicians (thoroughness, carefulness, competence)              

  • The helpfulness of the people in our business office: 

Please provide any additional comments

4.  Our Communication with You: 

 

Based on:

  • Timeliness of responding to your phone calls:            

  • Availability of medical information/advice by telephone:

  • Explanation and scheduling of your procedure/surgery:  

  • Education on upcoming procedures and surgery:

  • Timeliness of reporting your test results:   

  • Helpfulness of staff relaying referral/authorization requirements when you need one:

  • Ability to contact us after hours:  

Please provide any additional comments

        

 

5.  Your Visit with the Doctor:   

 

Based on:

  • The doctor listening to you 

  • The doctor taking time to answer your questions

  • The amount of time the doctor spent with you 

  • The explanation of treatment options 

  • The explanation of surgical procedure if applicable  

  • Thoroughness of examination

  • Instructions regarding medication/follow-up care

  • Satisfaction with treatment outcome prescribed by your doctor 

Please provide any additional comments

6.  Our Facility:    

Based on:

  • Hours of operation convenient for you 

  • Overall comfort 

  • Adequate parking and building access

  • Signage and directions

Please provide any additional comments

7.  Our Web Site:  

Based on:

  • General Medical Practice/Physician information given were helpful

  • Office Location and maps were helpful

  • Patient Education on procedures and surgery were helpful

  • Patient forms helped to speed office check-in process

  • Insurance information and links to their web site were helpful

  • Being able to provide feedback on-line is desirable

Please provide any additional comments or anything else you'd like added to this site:

8.  Your Overall Satisfaction  

Based on:

  • The quality of your medical care    

  • The quality of our practice

  • Would you recommend the doctor to others

Please provide any additional comments

 

Additional Information:

Please provide your email address: (required)           

Date of Exam:  (required)             mm/dd/yy 

Patient Initials (2): (required)           

Do you wish to have our patient representative contact you?

  • If yes, please give your name:

        

  • If yes, Daytime phone number:

         

Thank you for taking the time to provide feedback to us! 

We strive for continuous improvement.

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